Ординатура / Офтальмология / Английские материалы / The Slit Lamp Primer_Ledford, Sanders_2006
.pdf
78 Chapter 5
Figure 5-26. Iris cyst (note curve of beam where it hits the cyst). (Photo by Val Sanders.)
Figure 5-27. Peripheral iridectomy. (Photo by Val Sanders.)
•iris nevus – dark freckle (with feathered border) on iris surface; may be flat or slightly raised.
Doc: note, describe, give location, measure, draw
•iris strands – this looks like a little wispy hair coming off the iris and waving around in the aqueous. Sometimes the “hair” may have a blob of pigment stuck to it.
Doc: note, draw
• laser iridotomy – dot or area of iris that has been opened with laser. Is within iris, not at periphery (as in peripheral iridectomy, below).
Doc: note, give location by the clock, may describe as “patent” or “open” if unoccluded (these sometimes close; light will reflect through if open), draw
•normal iris vessels – iris vessels are not usually seen in the heavily pigmented iris. In light eyes they may be visible, but will coincide with the iris pattern and appear to be covered by a membrane. (Just because you see them does not mean it is rubeosis. In a healthy eye, it is probably just a prominent, normal vessel.)
Doc: note, give location by the clock, draw
• peripheral iridectomy (Figure 5-27) – wedge cut out of iris during surgery. Usually superior.
Doc: note, give location by the clock, may describe as “patent” or “open” if unoccluded (they are not likely to close, though), draw
Slit Lamp Findings 79
Figure 5-28. Peaked pupil. (Courtesy of Dennis Ryll.)
Figure 5-29. Iris rubeosis (note blood vessels on iris). (Courtesy of Dennis Ryll.)
•pigment dispersion – area(s) where iris pigmentation is missing.
Doc: note, grade 1+ to 4+
•pupil reaction – if the pupil is not dilated, it should react by getting smaller when the light from the slit lamp hits it. If there is no reaction, or the pupil enlarges, this is abnormal.
Doc: note, describe
•pupil shape – if the pupil is not round, it is abnormal (Figure 5-28).
Doc: note, describe (ie, “pupil peaked at 2:00”), draw
•rubeosis (Figure 5-29) – abnormal blood vessels on the iris surface. Usually seen in diabetes and trauma.
Doc: note, grade 1+ to 4+, draw
•sector iridectomy – whole wedge cut out of iris from periphery into pupil. Used to be done during cataract surgery without IOLs. Usually superior.
Doc: note, may give location of opening by the clock, draw
•synechia – portion of iris is stuck like glue onto the lens (posterior; Figure 5-30A) or back of cornea (anterior; Figure 5-30B). May see muscle fibers stretching from iris to other structure. If stuck to lens, the pupil margin may be irregular, and the eye may not dilate normally.
Doc: note if anterior or posterior, give location by the clock
80 Chapter 5
Figure 5-30A. Posterior synechia (note adhesions at carets). (Photo by Val Sanders.)
Figure 5-30B. Anterior synechia (note adhesion at caret). (Photo by Val Sanders.)
Lens/Intralocular Lens
•capsule opacity – white cloud on membrane behind IOL. May be general haze or may be only in a particular spot.
Doc: note, grade density 1+ to 4+, give location by the clock, note whether or not optic zone is clear, draw
•capsulotomy (Figure 5-31) – lasered hole in the posterior capsule. If pupil is not dilated and you do not know that the patient has had a capsulotomy, it can be hard to tell if a capsulotomy has been done. Everything behind the IOL looks black (same as a clear capsule). When dilated, it is easy to see the edges of the capsulotomy. Every now and then the capsulotomy hole is not central, and the optic zone still has an opacity.
Doc: note, may describe as “patent” if it is open (although they do not close), comment if optic zone is still obstructed, draw
• cataract – general term for any opacification of the lens (Table 5-8).
Doc: note, describe (including shape, texture, and color), give location, tell if optic axis is affected, grade density 1+ to 4+, draw
•cortical cataract – whitish lines, dots, or streaks (spokes) in the lens cortex. May be arrowshaped (wider at the periphery, point at center) or like spokes of a wheel. Spokes may be
Slit Lamp Findings 81
Figure 5-31. Patent posterior capsulotomy (note edge of opening at caret). (Photo by Val Sanders.)
TABLE 5-8
Types of Cataracts*
Type of Cataract |
Localization and Appearance |
Comments |
Congenital (formed in utero or during infancy)
1. |
Polar |
Anterior or posterior (axial area) of the |
|
|
lens capsule; appears as fine white dots |
2. |
Zonular (Lamellar) |
Gray round opacities surrounded by a |
|
|
dark, clear zone; can occur in preor |
|
|
postnatal development |
Usually hereditary; commonly remains stationary throughout life; visual acuity is only affected if opacity is large
Hereditary; usually occurs bilaterally; has tendency to increase in size during 3rd to 5th decade
Presenile (formed during early childhood/young adulthood)
1. Coronary Wreath of opacities in periphery of cortex
Senile (appearance generally following ages 30 to 40)
1. Nuclear Sclerosis (NS) Lens nucleus normally hardens with age; index of refraction of nucleus increases, inducing myopia; the world appears “yellower” as the lens acts as a filter for blue wavelengths
Appears in puberty; inherited; need widely dilated pupil to view, vision rarely affected
Myopic changes in Rx (“second sight”); slow, gradual reduction in vision
2. |
Cortical (Cort) |
Cortex absorbs water and swells, creating |
|
|
radial opacities (waterclefts); can |
|
|
progress to form cortical spokes |
3. |
Posterior Subcapsular |
Opacity on the posterior capsular face; |
(PSC) |
appears along optical axis or just |
|
|
|
inferiorly |
Toxic or Complicated
1. |
Steriods |
Typically PSC types |
2. |
Miotics (PI, DFP) |
Anterior subcapsular opacities |
3. |
Infrared (glass blower’s) |
Anterior lens capsule exfoliation |
4. |
Copper (chalasis) |
Sunflower cataract in subcapsular cortex |
5. |
Iron (siderosis) |
Brownish subcapsular opacity |
6. |
X-rays |
PSC type |
7. |
Chronic inflammation |
PSC type |
Can occur in combination with other senile lens changes
Appears as dark irregularity in retroillumination; glare, especially at night, is common complaint; this type can be most visually impairing due to its axial placement and density
*Adapted with permission from Nemeth SC, Shea CA. Medical Sciences for the Ophthalmic Assistant. rev. ed. Thorofare, NJ; SLACK Incorporated; 1991.
82 Chapter 5
TABLE 5-9
Grading Cortical Cataracts
|
Feature |
|
Grade |
|
|
|
Gray lines, dots, and flakes aligned along the cortical |
1+ |
(early or incipient) |
|
|
|
fibers in periphery; visible in oblique direct illumination. |
|
|
|
|
|
Opaque spokes, anterior chamber may be shallower |
2+ |
(immature or intumescent) |
|
|
|
than normal for patient |
|
|
|
|
|
Cortex opaque up to capsule, anterior chamber may again |
3+ |
(mature) |
|
|
|
be normal depth |
|
|
|
|
|
Lens is smaller, wrinkly capsule, nucleus may float in |
4+ |
(hypermature) |
|
|
|
liquefied cortex |
|
|
|
|
|
|
|
|
|
|
|
Figure 5-32. Nuclear sclerotic |
|
|
|
|
|
|
|
|
|
|
|
cataract. (Photo by Val Sanders.) |
|
|
|
|
|
|
|
|
|
|
so peripheral that they are only seen when dilated. Eventually cortex may liquefy and nucleus “floats”.
Doc: note, grade 1+ to 4+ (Table 5-9), describe location by the clock, note if spoke extends into the optic zone, draw
•intraocular lens (IOL) – plastic implant inserted during or after cataract surgery. If the lens is in front of the iris, it is an AC lens. If the lens is AC but clipped into the iris (with pegs or clips), it is an iris plane. An IOL behind the iris and pupil is a PC lens. The lens should be centered, but rarely they slip or drift (this is best seen after dilation).
Doc: note according to location (AC, iris plane, PC), type (if known), centration (note, draw)
•nuclear sclerosis (Figure 5-32) – generalized yellowing of the lens. If the color is more brownish, it is termed “brunescent.” If totally white and opaque, it is “mature.”
Doc: note, grade 1+ to 4+ (Table 5-10), note color abnormalities
• opacity – any cloudy area.
Doc: note, describe (color, size, location), draw
•posterior subcapsular cataract (Figure 5-33) – whitish opacity on the far back part of the lens. Can be hard to see (especially if you are trying to see through nuclear sclerosis). May be best viewed in retroillumination.
Doc: note, grade 1+ to 4+ (Table 5-11)
|
|
|
Slit Lamp Findings 83 |
|
|
|
|
|
|
|
|
TABLE 5-10 |
||
|
|
Grading Nuclear Sclerotic Cataracts |
||
|
Lens Color |
|
Grade |
|
|
Gray-blue (normal) |
0 |
|
|
|
Yellow overtone |
1+ |
|
|
|
Light amber |
2+ |
|
|
|
Reddish brown |
3+ |
|
|
|
Brown or black, opaque, |
4+ |
|
|
|
no fundus reflection |
|
|
|
|
|
|
|
|
|
|
|
Figure 5-33. Posterior subcapsular |
|
|
|
|
||
|
|
|
cataract. (Photo by Val Sanders.) |
|
|
|
|
|
|
TABLE 5-11
Grading Posterior Subcapsular Cataracts
Feature |
Grade |
|
Optical irregularity on posterior capsule; visible |
1+ |
|
only on retroillumination |
|
|
Small, white fleck |
2+ |
(early) |
Enlarged plaque; round or irregular borders |
3+ |
(moderate) |
Opaque plaque |
4+ |
(advanced) |
•precipitates (Figure 5-34) – brown dots, or may be a fine brown weblike deposit on IOL.
Doc: note, grade 1+ to 4+
•pseudoexfoliation (Figure 5-35) – gray dandrufflike flecks on lens (may also appear on pupillary margin).
Doc: note, grade 1+ to 4+, give location
• subluxation – the lens has slipped out of place partially or entirely.
Doc: note, describe, draw
84 Chapter 5
Figure 5-34. Precipitates on an IOL implant. (Photo by Val Sanders.)
Figure 5-35. Pseudoexfoliation. (Photo by Val Sanders.)
• vacuoles – look like little bubbles in the lens.
Doc: note, draw
Vitreous
•asteroid hyalosis – small, yellow, oval opacities (called miscelles) “stuck” in the vitreous gel. Highly reflective calcium, usually occurs in one eye only.
Doc: note, grade 1+ to 4+
•opacities – often golden, yellow, or white. May be red or white blood cells, cholesterol, or calcium. Best seen through dilated pupil.
Doc: note, describe
•syneresis scintillans – small, angular, golden crystals that float freely in the vitreous. Usually occurs in both eyes, often related to vitreous degeneration/liquification (syneresis) or old trauma.
Doc: note, grade 1+ to 4+
•vitreous strands – look like strands of eggwhite in the anterior chamber. May be floating through the pupil, still attached to the vitreous face. May run to wound site (internally).
Doc: note, describe, draw
Chapter 6
The Problematic
Examination
K E Y P O I N T S
•Many systemic diseases cause eye problems that can be detected with the slit lamp.
•Even if a systemic condition itself does not directly affect the eye, the eye may be affected by medication taken for that condition.
•There is the possibility of a local allergic reaction with virtually any topical ocular medication.
86 Chapter 6
OptT
OphA
You glance at the patient’s chart before calling her back. This is a follow-up exam for dry eye. What should you be especially looking for on her slit lamp exam? The first section of this chapter lists common ocular diseases and conditions with specifics to be cognizant of as you do the microscopic evaluation. The second section covers common ocular trauma.
The next patient in your exam chair gives a history of gout, for which he is taking allopurinol. Did you know that these can affect what you see during the slit lamp exam? The third part of this chapter lists systemic diseases and conditions in alphabetical order, followed by possible slit lamp findings. In the fourth section, systemic medications are listed by both generic and trade names, with details on potential microscopic affects. Finally, the fifth section lists topical ocular medications (by generic name, trade name, and sometimes category) and their possible slit lamp detectable side effects. For the patient mentioned above, you would look for episcleritis, scleritis, corneal crystals, and iritis associated with the inflammatory process in gout. You would also watch for cataracts, a possible side effect of allopurinol. Take a thorough history, identify possible ocular findings, and offer your patients the most careful slit lamp examination available!
Ocular Diseases and Conditions
Notes:
Some of the possible findings are admittedly rare.
Some of the possible findings may be absent in a particular patient or case. See also notes on medications used to treat these conditions.
•blepharitis: chalazion formation, collarettes, crusting/matting, lid edema, lid erythema, froth, lash loss, lid notching, packed meibomian glands, trichiasis, decreased tear BUT, debris in tear film, matter, oily tear film, conjunctival dryness, conjunctival injection, stained corneal dry spots, punctate epithelial erosions.
•cellulitis: lid edema, lid erythema.
•conjunctivitis: crusting/matting, debris in tear film, epiphora, matter, oily tear film, conjunctival edema, follicles, conjunctival injection, papillae, punctate epithelial erosions/stained areas.
•contact dermatitis: lid edema, lid erythema, lid rash, tissue sloughing.
•corneal dystrophy: corneal edema, corneal opacities, increasing corneal thickness, vascularization, bullae, recurrent epithelial erosion.
•dacryocystitis: redness medial to inner canthus, swelling medial to inner canthus, crusting/matting, epiphora, matter, reflux.
•dry eye syndrome: blepharitis, lid position (lower puncta may not contact globe), decreased tear BUT, debris in tear film, oily tear film, conjunctival dryness, conjunctival injection, stained corneal dry spots, desiccated tissue (stains with rose bengal).
•ectropion: lower puncta does not contact globe, epiphora, injection of palpebral conjunctiva, conjunctival dryness (inferior), conjunctival injection, stained corneal dry spots.
•endophthalmitis: lid edema and spasms, conjunctival erythema, conjunctival chemosis, corneal edema, marked anterior chamber reaction that may include an hypopyon.
•entropion: trichiasis, reduced tear production, conjunctival injection, corneal abrasions/keratitis (from lashes rubbing cornea), corneal scarring, corneal ulcer.
•episcleritis (Figure 6-1): increased tearing, episcleral injection (redness of vessels deeper than the conjunctiva, do not bleach on instillation of phenylephrine); red, blue, or purple
The Problematic Examination 87
Figure 6-1. Episcleritis (note raised nodule). (Reprinted with permission from Medical Sciences for the Ophthalmic Assistant, SLACK Incorporated.)
Figure 6-2. Giant papillary conjunctivitis. (Photo by Val Sanders.)
raised nodule; conjunctival/episcleral salmon-pink patch; corneal dellen; corneal edema; infiltrates.
•exophthalmus: incomplete lid closure, lid lag, lid malposition, epiphora, conjunctival dryness, scleral show, stained corneal dry spots (see also associated causative disorders).
•giant papillary conjunctivitis (Figure 6-2): mucus discharge, papillae on palpebral conjunctiva of upper lid.
•Herpes simplex: lid lesions (primary), follicles, watery discharge, conjunctival injection, corneal dendrite, corneal edema, corneal scarring.
•iritis (anterior uveitis, Figure 6-3): ciliary flush, keratitic precipitates, cell and flare in anterior chamber, miotic pupil, posterior synechiae.
•keratitis (inflammatory disorder): decreased tear BUT, watery or purulent discharge, conjunctival injection, conjunctivitis, corneal dry spots, corneal infiltrates, corneal ulcer, corneal staining.
•keratoconus (ectatic corneal dystrophy): lower lid distended by corneal cone in downgaze, blue sclera, central corneal thinning, corneal scarring, vertical striae, Fleischer ring, visible stromal nerves, breaks in endothelium and/or Descemet’s membrane, corneal edema.